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Severna Park Medical Associates

Adult Internal Medicine
31 Robinson Road

Severna Park, MD 21146

Phone: 410-544-5900

Fax: 410-544-5939

Patient Information Health Form

Please Note: Fields with the  * are required. 

 

Name: *

Date of Birth: *

Please List Your Allergies to Medications List Any Other Allergies
Previous Hospitalizations since Childhood 
(List Date and Reason for Hospitalization,
Include any surgery, such as tonsillectomy)		 List any chronic medical problem such as
high blood pressure, diabetes,
elevated cholesterol

List your current medications,
including supplements, vitamins
or over the counter products
like aspirin.
please include the dosage

 If you have children list their sex and ages
Are you married or single?  
Do you smoke?           If yes, how often?
Do you drink alcoholic beverages?  If yes, how much and how often?
Occupation:
Do you use any drugs? If yes, what kind and how often?
Do any illnesses such as high blood pressure, heart disease, diabetes, colon cancer, breast cancer or prostate cancer run in
your family? Please list the disease and family member below:
Please check any health problem below that you have had in the past:
Eye problems:  
  • Glasses for reading or distance
  • Cataracts
  • Eye injuries
  • Macular degeneration
  • Other

Endocrine Problems:  

  • Diabetes
  • Thyroid problems
  • Problems with adrenal glands
  • Other

Blood Problems:

  • Anemia
  • Low platelet count
  • Bleeding or coagulation problems
  • Other

Joint problems:

  • Rheumatoid arthritis
  • Osteoarthritis
  • Lupus
  • Joint injuries
  • Back problems
  • Other

GI problems:

  • Heartburn
  • Constipation
  • Diarrhea
  • Colitis
  • Other

Heart or Lung Problems:

  • Chest pain
  • Asthma
  • Shortness of breath
  • Cough
  • Difficulty exercising
  • Other

Neurological Problems:

  • Strokes
  • Seizures
  • Tremors
  • Weakness or numbness
  • Other

Kidney Problems:

  • Difficulty urinating
  • Leakage
  • Enlarged prostate
  • Kidney stones
  • Frequent infections
  • Other
Email:

 

 

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